Incident investigation·November 5, 2021

On 11/5/21 2:20pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit on recent incident reports of falls. LPA spoke with Administrator Morgan Whinery via phone and explained the purpose of the visit. Morgan was unable to be present and gave permission for Ian Phitsanoukanh, resident care coordinator to accompany LPA and sign in her absence. LPA toured facility with Ian to ensure Title 22 compliance and safety. All sharp objects and toxins were secured. Memory care door was functioning properly including alarm device. Room temperature was 75*F throughout facility. There were no obstructions to fire exit noted. There are 5 caregivers and 2 med techs for AM shift, 4 caregivers and 2 med tech for PM shift, and 2 med tech/caregiver are scheduled for noc shift with on-call available. LPA reviewed fall incident reports and resident files for Resident1 (R1), R2, R3, R4, R5, an R6. Falls were reported between the dates of 9-25-21 and 10-14-21. LPA also interviewed Administrator, and Ian Phitsanoukanh. Of the 6 resident falls reviewed, 4 were unwitnessed falls. All reporting requirements for incident reports received were met per regulations. Based on interviews, it was determined that facility has now implemented a fall prevention program as of 9-25-21 which includes safety protocols and in-service training. LPA reviewed fall prevention program. Fall prevention training was noted to occur on 10-28-21. Needs and service plans for R1, R2, R3, R4, R5, and R6 were reviewed by LPA. LPA observed resident rooms with fall preventions in place. As a result of this visit, no deficiencies are cited. An exit interview was conducted with Ian Phitsanoukanh and a copy of this report was left with Ian.